Cleveland_Well Abandonment_20221122

WELL ABANDONMENT RECORD Forlmarnalu"ONLY:
1.Well Contractor Inf tIon: WM ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning wen on his/her property) well construction/depth,only(GW-30 is needed. Indicate TOTAL NUMBER of
/ wells abandoned:
NC well Contactor Cet0cation Number 7b.Apprordmate volume of water remaining in well(s):
C. �\` �r�\`�t nZ ►1 r` FOR WATER SUPPLY WELLS ONLY-
company Name 7a Type of disinfectant used; ` o
2.Well Construction Permit#. ,1 4—
List aU gwkcabk well aonstrrrerion perndb(te.UIC,County,Starve l'ar*mm dc.)trbm m 7&Amount of disinfectant used; `
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑Mu/nicipal/Mlic ❑Neat Cement E F t'r,� tips or Pellets
❑Geothetmai(Heating/Cooling supply) �rdential Water supply(single) ❑� �y
❑lndtrstrial(Con mercial ❑Residential Water supply(shared) N O V 2 2 2 02 2 0•
❑Irri lion ❑Specialty Grout
Non-Water Supply Well: ❑Bentonite Slur(P iOUDI Pr.>_-OwkirQ d (explain under 7g)
❑Monitoring ❑Recovery —
Injection Well: 7E For each teriel selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier L '
Test ❑StormwaberDtainage
Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer a
❑Geothemnal Rerun ❑Other lain undo 7
4,Date well(,)abandoned:
Ss..Well location:
Fecrlity/Owner Name Facility W#(if applicable) 8• don:
cr D a 3 1(, �_ NC (�\ o�
Physical Address,City,and Zip c S' of Cormaetor or well owner Date
% ` By si form,I hereby certify that the wells)was(were)abandoned in
y Parcel IdeMifimtion No.(P1N) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the weU owner.
5b.Latitude and longitude In degmedminatesheconds or decimal degrees:
(if well field,one hMong is sufficient) �� 9.Site diagram or additional well details:
O � C) l t (/ D �) 5 You may use the back of this page to provide additional well site details or well
4 N O , W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTIORDETAILS OF WELL(S)BEING ABANDONED SUnnlr-
rrAr.1NSTRU ONS
Aaw.h well conseucaonrecord(s)I/'availabla For mul*kt4ecuonorson-wara'supplywdb —
ONLY ufA the same consauctiortlabando mrent you can submit meform. 10a.For All Well: Submit this form within 30 days of completion of well
• 6a.Well ID#: abandonment to the following-
Division of Water Resources,Information Processing Unit,
6b.Total well depth: () (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level blow ground surface: o (g,) Division of Water Resources;Underground Infection Control Program,
1636 Mail Service Center,Raleigh,,NC 27699-1636
6e.Outer casing length(if known): (g) 10c.For Water Sannly&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy-of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f,Inner casing/tubing length(if known): 00 abandoned
6g.Screen length(if known): ( )
Form GW-30 North CsmUm Department of Eavironmeutal Quality-Division of water Resources Revised 2-22-2016